Principles of Treatment. Case Studies. Principles of Treatment. Clinical Perspectives for the GP

Transcription

1 Principles of Treatment Clinical Perspectives for the GP Case Studies 1. Jumping athlete with an acute exacerbation of chronic patellar tendinopathy major competition in 9 days time 2 week tournament 2. Recurrent calf tears in a 40 year old long distance running athlete, 1-2 hr runs 3. Elite basketball player, 9 months out from major championship; ruptures ACL, MCL and sustains articular cartilage damage Principles of Treatment 1. Minimize the extent of initial damage 2. Promote tissue healing (mechanotransduction) 3. Maintain functional capacity 4. Graded return to sport 5. Aim to prevent recurrence 1

2 Learning Objectives Briefly describe common sports medicine treatments Discuss the trends in the use of various common sports medicine treatments Common Sports Medicine Treatments RICE Therapeutic drugs Manual therapy Exercise prescription Surgery Other (electrotherapy, acupuncture, dry needling, ESWT, sclerotherapy) RICE Common Pitfalls Distinguish between on-field vs postgame treatment R = relative rest Just RI Elevate onto a low table, not above the level of the heart 15 minutes is plenty Contraindication: Raynaud s, cold allergy 2

3 Immobilisation (part of rest) Lengthy immobilisation has deleterious effects Protected mobilization Use tape or brace Crutches CPM after surgery Benefits likely due to joint nourishment and mechanotransduction Therapeutic Drugs Panadol (paracetamol) as effective as NSAIDs for OA, even before problems with CV side-effects of Cox-II inhibitors surfaced NSAIDs Therapeutic Drugs Much less confidence in these drugs for sports medicine than 10 years ago Efficacy questions; data for improved outcome after acute injury (e.g. ankle sprain) are lacking No evidence for NSAIDs in tendinopathy Cox-II inhibitor concerns 3

4 Corticosteroids Therapeutic Drugs Waning use of these drugs in sports medicine Systematic reviews, meta-analysis fail to support their use Mechanism of pain relief not understood when pathology is not inflammatory GTN Nitric oxide patches (Nitro-Dur) one-quarter of a 5-mg/24-hour Nitro-dur patch Effective for tendinopathy (RCT evidence) Elbow, rotator cuff, Achilles tendons Headache main side-effect Mechanism likely due to stimulation of collagen synthesis rather than vascular effect George Murrell (Sydney surgeon) and Justin Paoloni (Sp.Physician) Manual Therapy Mainstay of high quality physiotherapy Physio manual therapy Massage Neural stretching Muscle energy techniques 4

5 Manual Therapy Joints Mobilization Manipulation Traction Muscles Massage therapy Muscle energy techniques Neural structures Neural stretching Joint mobilization Manual Therapy Passive movement technique Relies on careful clinical assessment For stiffness For pain Use for spinal / peripheral joints (e.g., ankle) Aim Joint Mobilization Restore joint range of motion Regain physiological movement Regain accessory movement 5

6 Mechanism Joint Mobilization Remains under study Several credible hypotheses Mechanical influence on joint Hypoalgesia effect Still being investigated but numerous RCTs speak to the effectiveness of joint mobilisation in reducing pain Joint Manipulation Sudden movement or thrust Small amplitude High speed End of range Patient unable to prevent the movement Primarily at intervertebral joints Machine or manual Joint Traction Manual still popular Traction apparatus joint traction (back pain, neck pain) becoming less popular compared to mobilisation, etc. 6

7 Massage Therapy Clinical evidence, rather than RCTs, in general May succeed via mechanotransduction (pressure effect) Reduce excessive adhesions Reduce spasm resulting from pain Muscle Energy Techniques Osteopathic techniques for assessment and correction of asymmetry or dysfunction (or both) of the musculoskeletal system. Hamstring tear results in adaptive posterior rotation of the ilium on the sacrum Techniques commonly used around the pelvis to treat back and leg pain Neural Stretching Upper limb tension test Slump test Aim is to restore normal tension and mechanics of the nervous system Think of it as neural flossing 7

8 Overview Common sports medicine treatments: RICE Therapeutic drugs Manual therapy Exercise prescription Surgery Other (electrotherapy, acupuncture, dry needling, ESWT, sclerotherapy) Exercise Prescription Discussed in detail in the Principles of Rehabilitation lecture Can be used to stimulate repair, e.g., tendinopathy Hakan Alfredson with Lars Ohberg Chronic Achilles Tendinopathy Eccentric Training 8

9 Exercise Prescription: A Mainstay Mechanism of action is likely via mechanotransduction (cell communication) that promotes repair Overview Common sports medicine treatments: RICE Therapeutic drugs Manual therapy Exercise prescription Surgery Other (electrotherapy, acupuncture, dry needling, ESWT, sclerotherapy) Surgery Arthroscopic surgery had been a tremendous advance Pioneered at the knee Now commonplace for the wrist, elbow, ankle, hip Endoscopic surgery being used in the ankle 9

10 Shoulder Common Sports Medicine Arthroscopic Surgery Labral tears, subacromial decompression, even rotator cuff repairs! Knee Ankle Talar dome debridement, removal of loose bodies Hip labral tears Other Treatments Electrotherapy, acupuncture, dry needling, ESWT, sclerotherapy Electrotherapy is waning in popularity Acupuncture, dry needling have their advocates ESWT successful in some trials, not in others; not beneficial in acute tendinopathy Sclerotherapy Alfredson s group - promising preliminary results, rapid return to sport when it works Risk of complications reported as low. 10

11 Case Reviews 1. Jumping athlete with an acute exacerbation of chronic patellar tendinopathy major competition in 9 days time 2 week tournament Corticosteroid injection Massage Strengthening Modified training Case Reviews 2. Recurrent calf tears in a long distance running athlete Neural stretching Strengthening Gastrocnemius, soleus Remedial massage Orthotics Nutrition Case Reviews 3. Elite basketball player, 9 months out from major championship; ruptures ACL, MCL and sustains articular cartilage damage Early diagnosis and immediate surgery Early mobilisation Remedial massage Strength training Modified return to sport, NSAIDs 11

12 Summary Outlined several common sports medicine treatments Suggested that manual therapy and exercise therapy are gaining evidence Electrotherapy is not being used as much in sports physiotherapy 12